Form CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan

Medicare Prescription Drug Plan
Disenrollment Survey

The questions in this survey are about your former prescription drug plan.
The name and contract number of your former plan are -< PREV_BENEFIT>
Provided by

** [sequence]

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OMB 0938-1113

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Survey Instructions
Thank you for taking time to complete this survey! Your answers are very important to us
and will help other people with Medicare choose a health or drug plan.
You received this survey because records show you recently switched or dropped your
Medicare prescription drug plan.
How to complete this survey:
 Answer each question based only on your experiences with your former plan (the

plan name is printed on the cover of this survey).
 Answer each question thinking about yourself.
 Answer each question by putting an “X” in the box to the left of your answer,

like this:
X Yes


 Read all the answer choices before marking your answer.
 Some questions have instructions that tell you to skip questions that may not apply

to you. When this happens you will see an arrow with a note that tells you what
question to answer next, like this: [  If No, go to Question 3].
 Return your completed survey in the enclosed postage-paid envelope.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 09381113, with an expiration date of TBD. The time required to complete this information collection is estimated to
average 11 minutes per response, including the time to review instructions, search existing data resources, gather
the data needed, and complete and review the information collection. If you have comments concerning the accuracy
of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn:
PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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YOUR FORMER PRESCRIPTION DRUG PLAN
1. Our records show that you used to belong to this prescription drug plan:
< PREV_BENEFIT>
Provided by
but that you no longer belong to that plan. Is that correct?

 Yes, I left the prescription drug plan printed above  Go to Question 2
 No, I left a different prescription drug plan  Go to Question 2
 No, I did not switch plans or leave ANY  Stop.
prescription drug plan recently

Do not complete the rest of this survey.
Please return the survey in the enclosed
envelope.

2. Did you have to switch plans or drop your former Medicare
prescription drug plan for any of the following reasons?

 I moved outside of the area where the plan
was available

 I was dropped by the plan
 The plan was cancelled or discontinued in my area
 The plan was changed or discontinued by the
organization that provides my insurance
(such as a former employer or a union)

Stop.



Do not complete the rest
of this survey.
Please return the survey
in the enclosed envelope.

 None of the above  Continue survey, go to Question 3

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GETTING THE PRESCRIPTION
MEDICINES YOU NEEDED FROM
YOUR FORMER PRESCRIPTION
DRUG PLAN

GETTING INFORMATION OR HELP
FROM YOUR FORMER
PRESCRIPTION DRUG PLAN
As you answer the questions in this
survey, please think only of your former
prescription drug plan (whose name is
printed on the cover of this survey).
3. Did you ever try to get information
or help from your former plan’s
customer service?

5. How often was it easy to use your
former plan to get the medicines your
doctor prescribed?

 Never
 Sometimes
 Usually
 Always
 I did not use my former plan to get

 Yes
 No  If No, go to Question 5
4. How often did your former plan’s
customer service give you the
information or help you needed?

 Never
 Sometimes
 Usually
 Always
 I did not try to get information or
help from my former plan’s
customer service

any prescription medicines

6. Did you ever use your former plan to
fill a prescription at a pharmacy?

 Yes
 No  If No, go to Question 8
7. How often was it easy to use your
former plan to fill a prescription at a
pharmacy?

 Never
 Sometimes
 Usually
 Always
 I did not use my former plan to fill a
prescription at a pharmacy

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8. Did you ever use your former plan to
fill any prescriptions by mail?

 Yes
 No  If No, go to Question 10

REASONS YOU LEFT YOUR
FORMER PRESCRIPTION DRUG
PLAN
The next questions are about reasons
you may have had for switching or
dropping your former prescription drug
plan.

9. How often was it easy to use your
former plan to fill prescriptions by
mail?

 Never
 Sometimes
 Usually
 Always
 I did not use my former plan to fill a

11. Did you leave your former plan
because someone else signed
you up for the plan without your
permission?

 Yes
 No

prescription by mail

10. Using any number from 0 to 10,
where 0 is the worst prescription
drug plan possible and 10 is the best
prescription drug plan possible, what
number would you use to rate your
former plan?

12. Did you leave your former plan
because the dollar amount you had
to pay each time you filled or refilled
a prescription (copayment) went up?

 Yes
 No
 I did not have to pay for my

 0 Worst prescription drug plan











possible

1
2
3
4
5
6
7
8
9
10 Best prescription drug plan
possible

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prescription medicines

13. Did you leave your former plan
because you found a plan with a
lower copayment for prescription
drugs?

 Yes
 No

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14. Some people have to pay their
prescription drug plan a monthly
premium (fee) out of their own
pocket for prescription drug
coverage.

18. Did you leave your former plan
because it turned out to be more
expensive than you expected?

 Yes
 No

Did you leave your former plan
because the monthly premium went
up?

19. Did you leave your former plan
because the plan refused to pay for a
medicine your doctor prescribed?

 Yes
 No
 I did not have to pay my former

plan a monthly premium out of my
own
Pocket

15. Did you leave your former plan
because you found a plan with a
lower monthly premium?

 Yes
 No
 I did not have to pay my former plan
a monthly premium out of my own
pocket

16. Prescription drug plans have a list
of the prescription medicines they
will cover. Did you leave your former
plan because they changed the list of
prescription medicines they cover?

 Yes
 No
17. Did you leave your former plan
because a change in your personal
finances meant you could no longer
afford the plan?

 Yes
 No

 Yes
 No
20. Did you leave your former plan
because you had problems getting
the medicines your doctor
prescribed?

 Yes
 No
21. Did you leave your former plan
because it was difficult to get brandname medicines?

 Yes
 No
 I did not try to get brand-name

medicines through my former plan

22. Did you leave your former plan
because you were frustrated by the
plan’s approval process for
medicines your doctor prescribed?

 Yes
 No
23. Did you leave your former plan
because you did not know whom to
contact when you had a problem
filling or refilling a prescription?

 Yes
 No
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29. Did you leave your former plan
because you found another plan with
a higher Medicare star rating?

24. Did you leave your former plan
because it was hard to get
information from the plan about
which prescription medicines
were covered or how much a
specific medicine would cost?

 Yes
 No

 Yes
 No

OTHER REASONS FOR LEAVING
YOUR FORMER PRESCRIPTION
DRUG PLAN

25. Did you leave your former plan
because you were unhappy with
how the plan handled a question
or complaint?

30. Did you leave your former plan
because a family member or friend
told you about a better plan?

 Yes
 No

 Yes
 No

26. Did you leave your former plan
because you could not get the
information or help you needed
from the plan?

31. Did you leave your former plan
because an insurance agent or broker
told you about a better plan?

 Yes
 No

 Yes
 No
27. Did you leave your former plan
because their customer service
staff did not treat you with courtesy
and respect?


 No

32. Did you leave your former plan
because you saw a commercial or
advertisement for a plan you thought
you would like better?

 Yes
 No

Yes

28. Every year Medicare evaluates all
prescription drug plans and gives
them a star rating.

33. Did you leave your former plan
because you found another plan that
better met your prescription needs?

 Yes
 No

Did you leave your former plan
because it got a low Medicare star
rating?

 Yes
 No
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34. Did you leave your former
plan because you take very
few prescription medicines
and don’t need a prescription
drug plan?

 Yes
 No
ABOUT YOU

38. In the past 12 months, have you seen
a doctor or other health provider 3 or
more times for the same condition or
problem?

 Yes
 No  If No, go to Question 40
39. Is this a condition or problem that
has lasted for at least 3 months?

 Yes
 No

35. In general, how would you rate your
overall health?

 Excellent
 Very good
 Good
 Fair
 Poor

40. Do you now need or take medicine
prescribed by a doctor?

 Yes
 No  If No, go to Question 42

36. In general, how would you rate your
overall mental or emotional health?

 Excellent
 Very good
 Good
 Fair
 Poor

41. Is this medicine to treat a condition
that has lasted for at least 3 months?

 Yes
 No
42. Has a doctor ever told you that you
had any of the following conditions?
a. A heart attack
b. Angina or coronary
heart disease
c. High blood pressure
or hypertension
d. Cancer, other than
skin cancer
e. Emphysema, asthma
or COPD (chronic
obstructive pulmonary
disease)
f. Any kind of diabetes
or high blood sugar

37. In the past 12 months, how many
different prescription medicines did
you take?

 None
 1 to 2 medicines
 3 to 5 medicines
 6 or more medicines

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Yes

No























43. What is the highest grade or level of
school that you have completed?

47. Did someone help you complete this
survey?

 Yes
 No  If No, go to Question 49

 8th grade or less
 Some high school, but did not

graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate

48. How did that person help you?
Please mark one or more.




 More than 4-year college degree

 Read the questions to me
 Wrote down the answers I gave
 Answered the questions for me
 Translated the questions into my

44. Are you of Hispanic or Latino origin
or descent?



 Yes, Hispanic or Latino
 No, not Hispanic or Latino
45. What is your race? Please mark one
or more.

 American Indian or Alaska Native
 Asian
 Black or African-American
 Native Hawaiian or other Pacific

49. May we contact you again if we
have questions about your survey
responses or the health care
services you received?

 Yes
 No

Islander

 White

46. What language do you mainly speak
at home?

 Chinese
 English
 Russian
 Spanish
 Vietnamese
 Some other language (please print):

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language
Helped in some other way (please
print):

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THANK YOU FOR COMPLETING THIS SURVEY
Please return your completed survey in the postage paid envelope to:
MEDICARE SATISFACTION SURVEY
PO BOX 3416
HOPKINS, MN 55343-9740

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